APPs in leadership roles: Key opportunities and considerations for hospitals

Advanced practice nurses and physician assistants are playing increasingly important roles in patient care and organized leadership, stirring up a new set of challenges and opportunities for hospitals and health systems.

A growing workforce of advanced practice professionals is countering physician shortages across the U.S., and more of these clinicians are stepping into medical staff leadership positions. The Bureau of Labor Statistics estimates the NP and PA workforce will increase 36 percent and 37 percent, respectively, by 2026, compared to just 13 percent growth in the physician workforce.

This article was sponsored by The Greeley Company.

With so much growth in the APP workforce, it's no wonder these clinicians are increasingly engaged in governance, management and leadership positions at hospitals and systems.

"APPs are engaged in all clinical aspects of healthcare delivery and provide the opportunity for a well-rounded, collaborative medical staff leadership team," says Sally Pelletier, chief credentialing officer at The Greeley Company, a national healthcare consulting and professional services firm in the greater Boston area.

The Greeley Company coined the term APP in 2008 after recognizing the industry's need to identify non-physician healthcare professionals who provide medical care and need to be privileged through the medical staff process, according to Ms. Pelletier. "At the time, there was a lot of confusion in the field due to the term 'allied health professional' being used to define both privileged and nonprivileged healthcare professionals," she says.

Physician assistants and advanced practice nurses — including certified registered nurse anesthetists, certified nurse midwives, nurse practitioners and clinical nurse specialists — fall under the umbrella of APP, which is now a widely used term in healthcare credentialing.

This article discusses the expanding role of APPs and identifies regulatory considerations and internal governance changes hospitals and health systems can implement to support these medical leaders as they step into leadership roles.

Then and now: How and why the APP role is expanding

APPs entered healthcare in the mid-1960s as a creative solution to fill care gaps and manage capacity issues created by physician shortages, particularly in the primary care area.

University of Colorado in Denver launched the first nurse practitioner program in 1965. By 1980, there were more than 200 NP programs available for students in the U.S, according to American Association of Nurse Practitioners.

The growth of APP positions throughout the past 50 years reflects the value hospitals and health systems see in deploying these individuals to support patient care. Yet because APPs first emerged to supplement the physician workforce, these clinicians initially lacked autonomy in healthcare settings, thus undercutting the benefits of their roles.

"APPs' initial scope of practice within the hospital setting was often limited with strict rules for co-signatures and/or requirements for the physician to also round the same day — essentially negating the benefit of the NP or PA," says Ms. Pelletier.

Fast forward four decades, and APPs are now gaining more autonomy and prominence than ever before, stepping into medical staff leadership roles traditionally held by physicians. These roles include medical staff officer and department chair positions, as well as chair or member positions on the hospital's credentials committee or medical executive committee with full voting rights.

"We are seeing this change in increasing numbers across the country," says Ms. Pelletier. She identified four major trends driving this role change for APPs.

1. A national physician shortage. The Association of American Medical Colleges projects the U.S. will face a shortage of up to 120,000 physicians by 2030. This deficit is due in part to an aging physician workforce; about 43 percent of physicians in the U.S. are 55 years or older, meaning a retirement wave is looming, according to a 2017 report from Merritt Hawkins. The healthcare industry will rely on APPs to fill these absences in the healthcare setting.

2. Increasing demands on physicians. Today's physician workforce is stretched thin — and getting thinner. A 2016 survey of 17,000 physicians conducted by Merritt Hawkins found 81 percent of primary care physicians were at capacity or overextended, and only about 19 percent said they had time to see more patients. These demands not only contribute to physician burnout but also increase wait times and decrease patients' face time with their providers. Hospitals are realizing APPs can help manage this demand and take some of the workload off physicians to create a more positive healthcare experience for both patients and providers.

3. A booming APP workforce. While the U.S. physician workforce shrinks, the APP workforce continues to exhibit tremendous growth. The number of nurse practitioners licensed to practice in the U.S. skyrocketed from 120,000 in 2007 to more than 248,000 in March 2017, representing a record-high total, according to data from the AANP. By the end of 2016, there were 115,547 certified PAs practicing in the U.S., up from approximately 108,000 in 2015, according to a report from the National Commission on Certification of Physician Assistants. The abundance of APPs will prove useful for hospitals that hire these clinicians and give them more responsibilities to support physicians.

4. A growing and aging patient population. The AAMC expects the U.S. population to grow 11 percent by 2030, with the number of Americans 65 and older growing 50 percent during the same period. This demographic shift will drive greater need for preventive and geriatric care that a physician workforce alone cannot accommodate. APPs, credentialed and capable of meeting most patients' preventive and chronic care needs, have a crucial role to play in meeting the demands of an aging population amid the intensifying physician shortage.

Hospitals must adapt as the roles of APPs change

APPs help hospitals and health systems address the physician shortage head on — whatever that deficit looks like for a specific health system or individual market. At the same time, updating bylaws and internal policies and ensuring continued regulatory compliance when APPs join the organized medical staff can prove to be a real headache.

To build a culture that is truly inclusive of APPs participating in the organized medical staff, hospitals and health systems need to revise medical staff guidelines, according to Ms. Pelletier. "Key areas that will need to be addressed are medical staff categories, including voting rights and other prerogatives, committee composition and fair hearing rights," she says. "And of course, the definition of who is included in the organized medical staff will need to be revised."

Healthcare organizations may need to update other accessory documents, such as rules and regulations and advanced practice policies, as applicable.

Hospitals and health systems must also understand the current regulatory landscape surrounding APPs, which is constantly changing. Each state has a different policy regarding NPs' and PAs' practice and prescriptive authority. While most states still require PAs to practice medicine through a supervisory relationship with a physician, some are moving toward looser regulations, according to Scope of Practice Policy, a collaborative project providing information on practice policy for various APP roles.

In December 2016, the U.S. Department of Veterans Affairs granted full practice authority to advanced practice registered nurses working in VA facilities, regardless of state restrictions. NPs can practice independent of physician oversight in 21 states and Washington, D.C., as of 2018, according to Stat News. Another six states have pending legislation to allow NPs to practice independently, according to Scope of Practice Policy's legislative database. PAs — once universally required to practice under physician supervision — are now also allowed to practice under a collaborative agreement in a handful of states with more legislation proposed to reduce restrictions, according to Ms. Pelletier.

If hospitals do not stay up-to-date with current regulatory restrictions and accreditation requirements, they may miss rules prohibiting or limiting APPs from specific leadership roles within the organized medical staff. Furthermore, a potential conflict of interest may occur if an APP is allowed to hold a leadership position within the medical staff, but still held internally to the requirement of having a supervisory relationship with a physician.

"It would be very awkward to have a supervised APP in a position of oversight for their supervisor," says Ms. Pelletier. "So while an organization wouldn't have to allow for a more independent practice for the APP (as allowed by state law) to align with increasing responsibilities and inclusivity into the medical staff, practicality indicates these two design decisions should align."


The medical staff of the future will look different from what hospitals are accustomed to due to changing healthcare demands and a transitioning medical workforce. The organized medical staff's transformation is already underway, and the inclusion of APPs in leadership roles is just one example, according to Ms. Pelletier. She cited additional innovative leadership models, such as service line co-management and other hybrid models, in which non-physician leaders directly oversee physicians.

Hospitals and health systems can be proactive by updating bylaws and ensuring regulatory compliance to achieve a smooth transition for APPs stepping into medical staff leadership roles. While these efforts can prove complicated and time-consuming, implementing proper protocols and regulatory considerations will translate into greater success for APPs on the medical staff and, ultimately, greater efficiency for hospitals and health systems.

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